High-risk tracheostomy: exploring the limits of the percutaneous tracheostomy.

OBJECTIVES: Modifications of the percutaneous tracheostomy (PercTrach) technique have made this a straightforward and safe procedure in appropriately selected patients. We sought to determine its value in high-risk patients.

STUDY DESIGN/METHODS: A retrospective study of high-risk and low-risk patients on whom bedside PercTrach was performed between May 2003 and October 2004 at the Medical College of Georgia. The patients were prospectively stratified into groups based on their comorbidities (morbid obesity or coagulopathy). The Ciaglia Blue Rhino introducer set was used in all cases.

RESULTS: Fifty-four consecutive patients were included in the study; the high-risk patients (n = 16) were younger than the low-risk (n = 38) patients (48.2 vs. 53.6 years, respectively), but had significantly higher Acute Physiology and Chronic Health Evaluation II scores (10.1 vs. 5.4, P = .0001). There were seven morbidly obese patients with a mean body mass index of 64.4 and a mean weight of 184.9 kg. There were 9 patients with a total of 10 coagulopathic conditions (7 = International Normalized Ratio [INR] of >1.5, 2 = heparin drip, 1 = platelet count < 20,000). One patient included in the study met requirements for two categories with a platelet count of 17,000 and an INR of 1.7. The procedural times ranged from 5 to 30 minutes. The high-risk PercTrachs took 14.4 +/- 5.0 minutes on average, compared with 12.2 +/- 4.8 minutes in the low-risk group (P = .115). One patient in the low-risk group bled from an anterior jugular communicating vein injury, requiring wound exploration and vein ligation. There were no other significant complications.

CONCLUSIONS: There were no statistically significant differences in intraoperative or perioperative outcomes between the PercTrachs performed in high-risk versus low-risk patients. PercTrachs may be performed safely even in high-risk patients such as those with morbid obesity and coagulopathy.